Vemco Group VOHS. 011.1 Accident and Incident Investigation Report Form - Phil's Version

VOHS. 011.1 Vemco Group Accident and Incident Investigation Report Form

• Report Date and Time

  Date

• Person Completing Report

• 

Part A

Incident Details

• Business Unit

  Select Veg South Veg North Construction Design Sevices SFS OTHER

  • Veg South
  • Veg North
  • Construction
  • Design
  • Sevices
  • SFS
  • OTHER

• Enter Name of Business Unit

• Location of Incident Enter the location of the incident or select from map.
  Address

• Date of Incident

  Date

• Description of incident.

• Photos of incident Provide a photo if possible.

  Media

• Were there witnesses to the incident?

  Yes

  No

• Witness Details

Witnesses

• Witness Name

• Witness Phone No if available

• Witness Address if available
  Address

• Recommendations (Reoccurrence Prevention) What Actions / Precautions could be taken to prevent this incident from re- occurring?

• Type of report

  Select Injury Environmental Customer Complaint Electrical Incident Plant & Equipment Private Property

  • Injury
  • Environmental
  • Customer Complaint
  • Electrical Incident
  • Plant & Equipment
  • Private Property

• List Persons Involved

Person(s) Involved

• Name

• Relationship to Vemco

  Employee

  Contractor

  Other Party

• Please enter the name and contact details of the contractor.

• Please provide name and contact details of other party.

• Mechanism of Injury

  Select Manual handling Slips and Trips Mechanical Failure Bites and Stings Electrical Contact Falling Objects / Working at Heights Vehicle Noise PPE - Incorrect or non existemt Struck by Foreign Object Other

  • Manual handling
  • Slips and Trips
  • Mechanical Failure
  • Bites and Stings
  • Electrical Contact
  • Falling Objects / Working at Heights
  • Vehicle
  • Noise
  • PPE - Incorrect or non existemt
  • Struck by Foreign Object
  • Other

• Describe Mechanism of injury

• Body Location

  Select Feet/ Ankle/Toes Knees/ Legs/ Hips Chest and Abdomine Shoulders and Arms Hands and Fingers Face/Head/ Neck Back Eyes Multiple Locations Other

  • Feet/ Ankle/Toes
  • Knees/ Legs/ Hips
  • Chest and Abdomine
  • Shoulders and Arms
  • Hands and Fingers
  • Face/Head/ Neck
  • Back
  • Eyes
  • Multiple Locations
  • Other

• Describe Body Location(s)

• What was the person doing at the time of the incident

  Select Cutting Vegetation from EWP Collecting Debris Getting in or out from Vehicle Driving Vehicle Equipment Repairs Climbing Cutting Vegetation from Ground Feeding Debris into Chipper Cross Arm Replacement / Pole Top Rot Installation of LV Equipment Conductor Repair Break Down Manual Handling Manufacturing Manual Handling Site Set Up Installing HV Equipment Installing HV/LV & SWER Earths to transformer and structures Pole Replacement Installing Transformer Onsite Service Testing Other

  • Cutting Vegetation from EWP
  • Collecting Debris
  • Getting in or out from Vehicle
  • Driving Vehicle
  • Equipment Repairs
  • Climbing
  • Cutting Vegetation from Ground
  • Feeding Debris into Chipper
  • Cross Arm Replacement / Pole Top Rot
  • Installation of LV Equipment
  • Conductor Repair
  • Break Down
  • Manual Handling
  • Manufacturing
  • Manual Handling
  • Site Set Up
  • Installing HV Equipment
  • Installing HV/LV & SWER Earths to transformer and structures
  • Pole Replacement
  • Installing Transformer
  • Onsite Service
  • Testing
  • Other

• Describe what the person was doing.

• Nature of Injury

  Select Fracture Dislocation Sprains and Strains Cuts and Abrasions Bites and Stings Foreign Body in Eye Ear or Nose Burns Poisining and toxic effects of substances Electric Shock Other

  • Fracture
  • Dislocation
  • Sprains and Strains
  • Cuts and Abrasions
  • Bites and Stings
  • Foreign Body in Eye Ear or Nose
  • Burns
  • Poisining and toxic effects of substances
  • Electric Shock
  • Other

• Describe the nature of the injury.

• Select Environmental Impact

  Air

  Water

  Land

  Flora

  Fauna

• Did the incident involve a spill?

  Yes

  No

  N/A

• Select spill type.

  Chemical

  Oil

  Fuel

  Soil

  Water

• Which one of the following was the ENVIRONMENTAL incident caused by?

  Select Fire Flooding Unauthorised Clearing Mechanical Failure Other

  • Fire
  • Flooding
  • Unauthorised Clearing
  • Mechanical Failure
  • Other

• Description of cause.

• What Immediate / Temporary controls have been put in place to control this Environmental Incident?

• Select the Plant and Equipment Type

  Select Motor Vehicle Equipment Plant Other

  • Motor Vehicle
  • Equipment
  • Plant
  • Other

• Enter Description

• Injury Type Classification

  Select Lost Time Injury Medical Treatment Injury First Aid Injury Injury No Treatment

  • Lost Time Injury
  • Medical Treatment Injury
  • First Aid Injury
  • Injury No Treatment

• Enter Identification Number if Available

• Vehicle Info

Vehicle

• Make

• Model

• Registration No

• Identification No.

PART B

Incident Risk

• 

• Categorise Risk Likelihood

  Almost Certain

  Likely

  Occasional

  Unlikely

  Rare

• Categorise Risk Consequence

  Severe

  Major

  Moderate

  Minor

  Negligible

• Using your responses above, select the overall category from the matrix diagram.

  L (Low)

  M (Moderate)

  H (High)

  E (Extreme)

• Complete the Accident and Incident Investigation Form. Notify HSEQ department and Supervisor /Manager

• Full investigation to be completed within 5 working days by investigation team. Notify HSEQ Manager and area / contract Manager

• Full investigation to be completed immediately by investigation team. Notify HSEQ Manager and EGM Immediately.

Contributing Factors

• Standard Conditions

  Select Inadequate Guards / Barriers Inadequate or Improper PPE Defective Tool and Equipment Congested or restricted action Inadequate Warning System Fire & Explosion Hazards Poor House Keeping Hazardous Environmental Condition e.g. smoke dust Noise Exposures Radiation Exposure Extreme Temperatures (Heat or Cold) Inadequate or Excess Light Inadequate Ventilation Other

  • Inadequate Guards / Barriers
  • Inadequate or Improper PPE
  • Defective Tool and Equipment
  • Congested or restricted action
  • Inadequate Warning System
  • Fire & Explosion Hazards
  • Poor House Keeping
  • Hazardous Environmental Condition e.g. smoke dust
  • Noise Exposures
  • Radiation Exposure
  • Extreme Temperatures (Heat or Cold)
  • Inadequate or Excess Light
  • Inadequate Ventilation
  • Other

• Standard Acts and Practices

  Select Operating Without Authority Failure to warn Failure to secure Operating at improper speed Failure to follow procedures / Training Overiding or removing safety devices Using defective equipment using equipment improperly Failure to use PPE Improper Loading Improper Placement Improper lifting Improper position for task Not using Lock Out Tag Out Horseplay Under influence of alcohol or drugs

  • Operating Without Authority
  • Failure to warn
  • Failure to secure
  • Operating at improper speed
  • Failure to follow procedures / Training
  • Overiding or removing safety devices
  • Using defective equipment
  • using equipment improperly
  • Failure to use PPE
  • Improper Loading
  • Improper Placement
  • Improper lifting
  • Improper position for task
  • Not using Lock Out Tag Out
  • Horseplay
  • Under influence of alcohol or drugs

• Details of contributing factors.

• Root Cause

  Select Leadership Supervision Instruction / Training Engineering / Design Purchasing Work Procedures Tools / Equipemnt Maintenance Wear and Tear Abuse or Misuse Natural Causes

  • Leadership Supervision
  • Instruction / Training
  • Engineering / Design
  • Purchasing
  • Work Procedures
  • Tools / Equipemnt
  • Maintenance
  • Wear and Tear
  • Abuse or Misuse
  • Natural Causes

• Detail of Root Causes

• In your opinion was this incident the result of an unsafe act or an unsafe condition?

  Unsafe Act

  Unsafe Condition

Part C

Associated Actions

• Details of actions / recommendations

• Priority

  L (Low)

  M (Moderate)

  H (High)

  E (Extreme)

• Who is accountable for ensuring these actions are complete?

Part D

• EGM or Operations Managers comments

• 

• Add signature

  Sign